Episodes Of Hematuria Research Articles

Transperitoneal Transvesical Robotic Simple Prostatectomy for a Greater Than 400G Enlarged Prostate Using the Multiport Robot

Introduction: In this video we demonstrate our surgical technique for approaching a massively enlarged prostate through a transabdominal transvesical approach using the multiport robotic platform. Materials and Methods: Here we present a case involving a 76-year-old man with history of enlarged prostate causing urinary retention with several episodes of gross hematuria, and clot retention. His prostate specific antigen was 18 ng/mL, and a prior transperineal prostate biopsy was negative for malignancy. The patient had a medical history of hypertension. Results: Operative time was 4 hours 48 minutes. Blood loss was 300 mL. Patient length of stay was 2 days. On follow-up 3 months postoperatively, the patient's postvoid residual bladder volume was 68 cc, International Prostate Symptom Score was 3, and quality of life score was 0. Conclusions: Transabdominal transvesical approach using the multiport robotic platform to perform simple robot-assisted prostatectomy is a feasible and safe option for treatment of a massively enlarged prostate. No competing financial interests exist. Patient consent: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music source: https://www.youtube.com/watch?v=R0j2o9DyI04 Runtime of video: 6 mins 22 secs

Ewing’s sarcoma of the right kidney with multiple metastasis on PET/CT

BackgroundEwing’s sarcoma is categorized as small round cell aggressive tumor which commonly occurs in bone and soft tissue. Primary renal Ewing’s sarcoma is an extremely rare entity and accounts for less than 1% of renal masses. It is characterized by a very aggressive course, with very few reported cases in the literature. Primary renal Ewing’s sarcoma is indistinguishable from renal cell carcinoma on anatomical imaging and therefore need histopathological correlation for confirmation. The positron emission tomography (PET) fused with computed tomography (CT) helps in the evaluation of disease, for staging and metastatic workup.Case presentationWe present a case of 48-year-old lady who presented to urology department with difficulty in passing urine for 5 months associated with pain in the right flank region. She had an episode of haematuria 5 months back. Contrast enhanced CT showed a large lobulated heterogeneously enhancing right retroperitoneal mass in renal fossa. Histopathological examination and immunohistochemistry were suggestive of Ewing’s sarcoma. The PET/CT revealed FDG avid right renal mass with lymph nodal and skeletal metastasis.ConclusionsEwing’s sarcoma being aggressive tumour usually present with bone, liver and lung metastasis along with lymph nodal metastasis at time of diagnosis. The 18 F FDG PET/CT helps in diagnosis, staging, appropriate treatment planning, restaging, response evaluation and prognostication of Ewing’s sarcoma.

IgA Nephropathy: Are We Doing Enough?

Immunoglobulin A nephropathy (IgAN) was first identified and described as a disease by Berger and Hinglais in 1968. It is the most common primary glomerulopathy worldwide [1], most prevalent in East Asians and Caucasians and rare in black individuals. There are four key elements that contribute to IgAN, which determine the severity, course, and prognosis of the disease: circulating IgA immunocomplexes that favor mesangial deposition, the efficiency of the reticuloendothelial system, mesangial cell affinity and reaction to mesangial accumulation of poorly glycosylated IgA1, and the renal tendency to glomerulosclerosis and interstitial fibrosis. Clinical manifestations among patients with IgAN include hematuria, approximately 40% to 50% of cases present with one or more episodes of hematuria, usually preceded by upper respiratory tract infections. Between 30% and 40% present with hematuria and non-nephrotic range proteinuria that may be associated with arterial hypertension and impaired renal function. The TESTING study reveal a significant decrease in outcomes such as the risk of a 40% decrease in glomerular filtration rate or the need for renal replacement therapy in the group treated with steroids. The decrease in renal function compared to the group treated in the previously mentioned STOP-IgAN trial was 4 times less than in the TESTING study. Are we doing enough? Obviously, more trials are required with the use of adequate nephroprotection measures. We present 3 patients with a diagnosis of IgA nephropathy who attend the follow-up consultation and voluntarily decide to take part in the review.

Medications mostly associated with hematuria: assessment of the EudraVigilance and Food and Drug Administration pharmacovigilance databases entries.

Drugs may have a direct causative role in triggering hematuria. The range of medications which may be responsible for hematuria is wide, but little is known on those which are most frequently involved. The aim of our study was to identify and compare drugs mostly related with hematuria. The Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database and the EudraVigilance (EV) database were queried to identify the drugs which were associated the most with hematuria individual reports till 30 September 2021. Rivaroxaban, aspirin, warfarin sodium, clopidogrel bisulfate, dabigatran etexilate mesylate, apixaban, warfarin, cyclophosphamide, lansoprazole, enoxaparin sodium, and ibuprofen were analyzed. Analysis per gender, age and severity was performed. Disproportional analysis was performed to compare drugs. Overall, 15,687 reports of hematuria were recorded in the FDA database and 15 007 in the EV database. Rivaroxaban and Warfarin appear to be the most dangerous medications in terms of hematuria when compared to the other medications (PRR>1, P<0.05) while apixaban is the safest one (PRR<1, P<0.05) when compared to the other medications. In terms of severity only 162/15 007 (1.08%) were fatal. Between the drugs analyzed cyclophosphamide 7.2%, enoxaparin (3%) and dabigatran (2.5%) presented a higher number of fatal hematuria episodes when compared to the other drugs (<1%). Anticoagulants and antiplatelets are more frequently related to hematuria episodes however some differences exist between them. Particularly warfarin and rivaroxaban should be prescribed with caution in patients at increased risk of hematuria. Prescribers should inform those treated with these medications about the risk of hematuria and its sequelae.

5α-reductase inhibitors and the risk of bladder cancer in a large, population-based cohort.

The ability of 5α-reductase inhibitors (5ARI) to reduce the risk of new onset bladder cancer (BC) has been studied with variable results. Our objective was to conduct a retrospective cohort population-based study to evaluate the association between 5ARI use, BC diagnosis, and BC mortality. We used routinely collected health care data from Ontario, Canada. Men ≥66 years of age with a prescription for a 5ARI were matched to non-5ARI users. Matching was done using a propensity score of selected covariates to make 96 different covariates comparable. We measured 5 additional baseline variables which may have impacted the risk of future BC diagnosis: prior cystoscopy, urine cytology, urinalysis, gross hematuria episodes, and transurethral resection of a bladder lesion. Only the first period of continuous usage of 5ARIs was considered. The prespecified at-risk period for outcomes started 1 year after initiating therapy and ended at the last date of 5ARI exposure + 1 year. We identified 93,197 men who initiated 5ARI therapy (52% dutasteride, and 48% finasteride) between 2003 and 2013 and matched them 1:1 to men who did not start a 5ARI. The median at-risk period for the 5ARI group was 1.68 years (interquartile range 1.00, 4.27). With adjustment for the variables related to prior BC investigations there was no significant difference in BC diagnosis (hazard ratio [HR] 1.05, 95% confidence interval [CI] 0.82-1.32) during the period of 0 to <2 years of 5ARI use; however, after ≥2 years of 5ARI use, the risk of BC diagnosis was significantly lower among the 5ARI group (HR 0.82, 95% CI 0.79-0.94). In a similarly adjusted model, BC mortality was lower among 5ARI users, but no longer statistically significant (HR 0.82, 95% CI 0.65, 1.02). When stratified by type of 5ARI, finasteride significantly reduced the risk of BC diagnosis after ≥2 years of continuous use (HR 0.86, 95% CI 0.76, 0.96); however, dutasteride did not (HR 0.92, 95% CI 0.83, 1.03). In a large cohort of men, the use of a 5ARI was associated with a significantly decreased the risk of BC diagnosis after more than 2 years of continuous therapy.

PS-C37-3: MULTIPLE VISITS TO THE EMERGENCY SERVICE - A CASE OF NUTCRACKER SYNDROME

Background: Nutcracker Syndrome (NS) is a rare clinical entity consisting of compression of the left renal vein by the superior mesenteric artery as it travels between it and the abdominal aorta. The compressive process leads to different levels of extrinsic renal artery stenosis, from asymptomatic episodes to episodes of macroscopic hematuria, proteinuria, renovascular hypertension, left flank pain, dyspareunia, dysmenorrhea and pelvic varicose veins. It is more prevalent in females and it can be diagnosed at any age, but particularly during the 2nd and 3rd decades of life. Renal veins Doppler ultrasonography is the exam of choice in the initial evaluation, being confirmed by imaging exams such as CT and MRI. The treatment is controversial, ranging from conservative treatment to nephrectomy. Case Description: Between 2015 and 2022, a 24-year-old Caucasian woman, without noteworthy personal and family clinical background, resorted several times to the Emergency Department with vomiting, diarrhea and abdominal distension and pain. Numerous alternative diagnoses have been made, such as Acute Gastroenteritis, Urinary Tract Infection, among other. Due to the large number of emergency episodes, the patient was examined by gastroenterologist who requested an abdominal CT, and diagnosed NS. The patient underwent an unsuccessful left renal vein stenting, which subsequently forced a renal auto transplantation, which was performed without complications. Take Home Message: In the GP daily practice, establishing NS diagnosis is difficult and usually made after the exclusion of other problematics. A great level of suspicion is therefore crucial in patients with diversified clinical findings.

Эффективность и безопасность интермиттирующей катетеризации для купирования острой задержки мочи: проспективное сравнительное рандомизированное исследование

of the study: to evaluate the effectiveness and safety of intermittent catheterization in the management of acute urinary retention and to identify factors influencing the resume normal voiding and the development of adverse events.129 patients admitted to urology department with acute urinary retention due to BPH were randomized into two groups. Group I had indwelling bladder catheterisation using Foly catheter. Group II was catheterized intermittently.Success rate, time to resume normal voiding, number of episodes of fever, pain, urgency and gross hematuria. Factors influencing the probability of AUR resolution and adverse events were also analyzed.Normal voiding was resumed in 25 (35.7%) patients in group I, and in 26 (44%) patients in group II. The probability of AUR resolution in group II was 1.5 times higher than in group I. However, this difference was not statistically significant. In group II normal voiding was restored within 1 day in 1 (3.8%) patient, in 12 (46.2%) - within 2 days, and in 13 (50%) - within 3 days. On the 7th day relapse of AUR occurred in 3 (2.3%) patients, in 2 (2,8%) patients in group I and in 1 (1.7%) patient in group II. Logistic regression analysis showed statistically significant association between the probability of developing gross hematuria and the age of the patient, as well as between possible urethrorrhagia and episodes of acute urinary retention previous to the last AUR episode. Statistically significant associations were revealed between age and the use of a-blockers at the time of the acute urinary retention episode and the probability AUR resolution. An increase in the patients age by 1 year was associated with decrease in the chances of voiding resumption by 1.07 times, and a-blockers therapy at the time of acute urinary retention increased these chances by 2.8 times. Urgency rate was statistically significantly higher in group I (30% vs. 3.4%), the chances of developing urgency were also 12 times higher in group I.Intermittent catheterization is an effective method of AUR management. The major advantages of this method are the possibility of outpatient treatment, maximum preservation of patients social and sexual activity, earlier resumption of voiding and significantly less common catheter-associated lower urinary tract symptoms.

Autosomal dominant polycystic kidney disease in young adults.

The clinical manifestations of autosomal dominant polycystic kidney disease (ADPKD) usually appear in adulthood, however pediatric series report a high morbidity. The objective of the study was to analyze the clinical characteristics of ADPKD in young adults. Family history, hypertension, albuminuria, estimated glomerular filtration rate (eGFR) and imaging tests were examined in 346 young adults (18-30 years old) out of 2521 patients in the Spanish ADPKD registry (REPQRAD). A literature review searched for reports on hypertension in series with more than 50 young (age <30 years) ADPKD patients. The mean age of this young adult cohort was 25.24 (SD 3.72) years. The mean age at diagnosis of hypertension was 21.15 (SD 4.62) years, while in the overall REPQRAD population was aged 37.6 years. The prevalence of hypertension was 28.03% and increased with age (18-24 years, 16.8%; 25-30 years, 36.8%). Although prevalence was lower in women than in men, the age at onset of hypertension (21 years) was similar in both sexes. Mean eGFR was 108 (SD 21) mL/min/1.73 m2, 38.0% had liver cysts and 3.45% of those studied had intracranial aneurysms. In multivariate analyses, hematuria episodes and kidney length were independent predictors of hypertension (area under the curve 0.75). The prevalence of hypertension in 22 pediatric cohorts was 20%-40%, but no literature reports on hypertension in young ADPKD adults were found. Young adults present non-negligible ADPKD-related morbidity. This supports the need for a thorough assessment of young adults at risk of ADPKD that allows early diagnosis and treatment of hypertension.

Risk of CKD Following Detection of Microscopic Hematuria: A Retrospective Cohort Study

Microscopic hematuria is an uncertain risk factor for chronic kidney disease (CKD). We investigated the association between persistent or single episodes of microscopic hematuria and the development of incident CKD, overall and separately among men and women. Retrospective cohort study. A total of 232,220 Korean adults without CKD at baseline who underwent repeated regular health examinations at Kangbuk Samsung Health Study formed the study cohort. Microscopic hematuria was defined by≥5 red blood cells per high-power field. Participants were categorized into 1 of 4 groups according to the presence of hematuria at 2 consecutive examinations: (1) no hematuria at both examinations (reference group); (2) hematuria followed by no hematuria (regressed hematuria group); (3) no hematuria followed by hematuria (developed hematuria group); and (4) hematuria at both examinations (persistent hematuria group). CKD was defined as an estimated glomerular filtration rate<60mL/min/1.73m2 or proteinuria (1+or more on dipstick examination). Semiparametric proportional hazards models were used to estimate hazard ratios. During a 4.8-year median follow-up period, 2,392 participants developed CKD. Multivariable-adjusted hazard ratios for incident CKD, comparing the regressed, developed, and persistent hematuria groups to the no-hematuria group were 1.85 (95% CI, 1.35-2.53), 3.18 (95% CI, 2.54-3.98), and 5.23 (95% CI, 4.15-6.59), respectively. The association between persistent hematuria and incident CKD was stronger in men than women (P for interaction<0.001), although a statistically significant association was observed in both sexes. Lack of albuminuria and inability to consider specific glomerular diseases. Men and women with microscopic hematuria, especially persistent hematuria, may be at increased risk of CKD.

Large de novo Renal Cell Cancer in Renal Allograft

Renal cell cancer (RCC) in renal allograft is a rare entity. We report a case of RCC successfully diagnosed in a 42-year-old renal allograft recipient which developed 13 years after engraftment. The patient was initially evaluated using ultrasound for two episodes of hematuria followed by contrast-enhanced CT scan revealing 9.7 cm × 8.6 cm × 6.5 cm heterogeneously enhancing mass at mid-pole with involvement of renal sinus. Allograft nephrectomy was performed. A genetic study with DNA microsatellite analysis showed de novo RCC from donor origin. Seven months after surgery, the patient is alive with no evidence of tumor recurrence and is now planned for a second renal transplant. To the best of our knowledge, this is the largest allograft RCC reported in the Indian scenario.

632 A Rare Case of Genitourinary Tuberculosis Presenting as Occult Compensated Renal Failure

Abstract It is acknowledged in the literature that genitourinary TB is a diagnostic challenge due to its rarity and insidious presentation. We herein report a case of a 64-year-old gentleman originally from Peru with an unremarkable past medical history that attended his GP practice on multiple occasions complaining of recurrent left sided loin pain, headaches, and microscopic haematuria. Abdominal ultrasonography revealed an atrophic left kidney and dilated renal pelvis. This was interpreted to either be a complication of chronic renal calculi, or secondary to malignancy. Further investigations including CT urogram, MAG3 renogram, cystoscopy and anterograde pyelogram effectively ruled out malignancy, revealing hydronephrosis and loss of cortical thickness. And although this was initially dismissed, further deterioration prompted more robust investigations. A complication of testicular pain and swelling with an associated lack of response to prolonged courses of antibiotics and associated scrotal abscess on ultrasonography prompted rapid surgical decompression and drainage. Histopathological results reported findings of acute necrotising granulomatous inflammation with positive acid-fast bacilli on Ziehl-Neelsen staining – consistent with tuberculosis. Routine follow up since commencing anti-TB therapy showed marked improvement with no further episodes of haematuria or flank pain, and kidney function remained at baseline. By raising awareness of potential imaging features as well as more subtle clinical presentations, it is hoped that clinicians can consider genitourinary tuberculosis as a differential, if there is no improvement with conventional antimicrobial agents.

Uretero-Iliac Artery Fistula

Uretero-Iliac Artery Fistula: a rare cause of haematuria A 90-year-old male presented to our hospital with a onemonth history of intermittent gross hematuria. He had stage II rectal cancer and received neo-adjuvant concurrent chemoradiotherapy and low anterior resection 5 years ago. Additionally, he was under regular bilateral ureteral catheter replacement due to radiation related ureteral stricture for two years.\r\nDuring examination, there was no abdominal tenderness or flank pain. Urine analysis showed pyuria and hematuria. Abdominal and pelvic computed tomography without contrast medium revealed only bilateralwithout contrast medium revealed only bilateral hydronephrosis. After admission, several hematuria episodes that required blood transfusions and bladder irrigation occurred at an interval of 3 days and resolved spontaneously. Cystoscopy was unmarkable except bleeding from right ureteral orifice during ureteral stent replacement. Concerns for a ureteral arterial fistula prompted an angiogram, which later on proved the existence of a fistula with pseudoaneurysm(Figure 1) between external iliac and distal right ureter(Figure 1). A stent graft was placed from the common iliac into the right external iliac artery. After stent-graft deployment, the aneurysm is no longer opacified. At the 2-month follow-up, no hematuria recurrence was detected.\r\n

Bladder Xanthoma

A 35-year-old male presented with multiple interrupted episodes of frank hematuria and persistent micro-scopic hematuria. CT urogram demonstrated a nonspecific lesion in the bladder. Cystoscopy showed a lesion in the bladder wall that was biopsied, and histopathology confirmed a xanthoma, a rare diagnosis in the bladder. This case report performs a review of current literature and examines necessary investigations,differential diagnoses, and management required for bladder xanthoma.

Giant uterus in a patient with Klippel-Trenaunay syndrome. Report of a case.

IntroductionKlippel-Trenaunay syndrome is an uncommon congenital disease also called angio-osteodystrophy syndrome for its typical disorders characterized by abnormal growth of the soft tissues and bones and vascular malformations.Case reportIn this report, we present a rare case of a 46-year-old nulliparous woman with Klippel-Trenaunay syndrome. She suffered from an abnormal uterine bleeding accompanied by severe anemia with need for multiple blood transfusions. At the time of admission, physical examination revealed port-wine stains and varicose veins on her lower limbs and hypertrophy of left lower extremity. We carried out an open bilateral hysteroannexectomy. Histopathology examination revealed a uterus weighing 6300 g with diffuse abnormal vasculature, leiomyomatosis and diffuse venous malformation.DiscussionKlippel-Trenaunay syndrome is considered a rare disease as it has an incidence of 2–5 on 100,000 with no differences between the both sexes. The clinical manifestations are related to the organs involved in the pathological angiogenesis therefore patients may also present cerebral, retinal, gastrointestinal and genitourinary anomalies with consequent occult or significant bleeding. Uterine involvement is very rare. The main clinical manifestations are represented by irregular episodes of hematuria and/or menometrorrhagia associated with important anatomical anomalies of the female reproductive system.ConclusionUterine involvement in patients with Klippel-Trenaunay syndrome, althought rare and with extremely variable clinical manifestations, is actually a relevant event that not only significantly affects the reproductive capacity of the woman but which potentially puts patients' lives at risk because of an unpredictable bleeding.

Use of tetrasodium EDTA acid for the treatment of intraluminal obstruction of subcutaneous ureteral bypass devices.

ObjectivesThe aim of this study was to evaluate the efficacy and tolerability of a 4% tetrasodium EDTA (tEDTA) infusion protocol in the subcutaneous ureteral bypass (SUB) devices of cats with intraluminal obstruction at a veterinary teaching hospital between July 2017 and April 2020.MethodsThis was a retrospective controlled study. Cats with an obstructed SUB device underwent a 4% tEDTA infusion protocol. Obstruction of the device was diagnosed based on renal pelvic dilation, dilatation of the ureter, mineralized material within the device (cystostomy or nephrostomy catheters) seen on ultrasound, the absence of visible bubbles within the renal pelvis and/or urinary bladder following ultrasound-guided flushing of the device with saline.ResultsA total of 16 tEDTA infusion protocols were performed in 14 cats. The infusion protocol was considered successful in 11/16 SUB devices (68.8%). Six devices (n = 6/11; 54.5%) had recurrence of obstruction with a median time of 87 days. One or more episodes of self-limiting pollakiuria and/or hematuria following infusion was seen in eight patients (n = 8/14; 57.1%).Conclusions and relevanceInfusions of 4% tEDTA successfully relieved intraluminal obstruction in patients with occluded SUB devices; however, the recurrence of obstruction was common. Additional studies evaluating case selection and optimal protocols are warranted.

Surgical Treatments of Benign Prostatic Hyperplasia and Prostate Cancer Stereotactic Radiotherapy: Impact on Long-Term Genitourinary Toxicity

AimsAlthough the results on acute and late toxicity of ultrahypofractionation are encouraging, data on safety in prostate cancer patients with a medical history of transurethral resection of the prostate (TURP) or adenomectomy remain scarce, especially in cases of repeated procedures. The aim of the present study was to report on long-term toxicities after stereotactic body radiotherapy (SBRT) of prostate cancer patients with previous surgical treatment of benign prostatic hyperplasia. Materials and methodsAmong 150 patients treated with SBRT (median dose 36.25 Gy in five fractions) realised from 2014 to 2019 in a single-centre institution, data of 24 men with a history of TURP (n = 19) or adenomectomy (n = 5) were analysed. Repeated TURP was carried out in three patients, with a median time between surgery and SBRT of 54 months. Genitourinary toxicity was assessed using the Common Terminology Criteria for Adverse Events v4.0 grading scale. ResultsWith a median follow-up of 45 months, 10 of 24 (42%) patients experienced at least one episode of transient haematuria. One patient (4%) with three previous TURP presented a grade 3 acute non-infective cystitis. Late grade 2 and 3 genitourinary toxicities were observed in eight (33%) and four patients (17%) (two treated with adenomectomy, one with multiple TURP and one with a 140 cm3 prostate size), respectively, with no grade ≥4 adverse events. A complete recovery of grade 3 genitourinary toxicities was observed for all patients after hyperbaric oxygen therapy. ConclusionProstate SBRT is feasible and well-tolerated in patients with a medical history of surgical treatments of benign hyperplasia. Patients with prior adenomectomy or multiple TURP are at higher risk of developing severe genitourinary toxicity and should be carefully evaluated before SBRT treatments.

A Term Neonate with Multiorgan Dysfunction, Severe Metabolic Acidosis, and Hyperkalemia.

A Term Neonate with Multiorgan Dysfunction, Severe Metabolic Acidosis, and Hyperkalemia.

Refractory hematuria post actinic cystitis. Role of potassium alumen as treatment - Case Report

Actinic cystitis hematuria is a frequent complication after pelvic radiotherapy, present in approximately 5% of patients exposed to this therapy. The management of these cases seems to be a challenge for today’s urologists. In this article, we present the case of a 73- year-old man diagnosed with actinic cystitis after pelvic radiotherapy and admitted to our service with a clinical picture of refractory macroscopic hematuria. During admission, the patient underwent multiple procedures and blood transfusions, without success in controlling hematuria. After a review of the literature, we chose to use Potassium Alum in the patient’s treatment. Under general anesthesia, we performed a cystoscopy with the evacuation of clots and subsequently infused a 1% solution of potassium alum into the bladder at a rate of 200 ml/h for 25 hours. Less than 24 hours after Alum infusion, there were no more clinical signs of hematuria, which remained until hospital discharge. After 6 months of treatment, the patient did not present another episode of hematuria.

P88 LEFT ATRIAL APPENDAGE CLOSURE DEVICE COMPLICATED BY LATE ONSET PERICARDIAL EFFUSION AND TAMPONADE: A CASE REPORT

Abstract Background Late onset complications of left atrial appendage occlusion (LAAO) device procedure are anecdotal and there are no such complications reported in literature using Cardia Ultraseal (Cardia, USA). Case Summary We report the case of a 74–year–old Caucasian man affected by paroxysmal atrial fibrillation with significant bleeding risk (familiar thrombocytopenia, macroscopic hematuria episodes during therapy with direct oral anticoagulants, HAS–BLED risk score: 4) and ischemic risk as well (CHADSVASC score: 3). The patient was treated with LAAO device implantation for high bleeding risk. Subsequently, after 26 days from LAAO procedure, he was admitted to the emergency department for hematic cardiac tamponade. The patient was successfully treated with subxyphoidal pericardiocentesis in the acute phase, unfortunately cardiac arrest occurred during the transfer to the referral hospital for urgent cardiac surgery. Permanent neurological damage was reported and the patient died on day 28. Discussion There are several clinical and radiological aspects that may suggest a cause–effect relationship with the occurrence of hematic pericardial effusion and LAA occlusion device implantation: firstly the pericardial effusion was hematic and its occurrence was preceded by acute interscapular pain suggesting an acute pericardial irritation caused by the hematic effusion and secondly, the CT scan played an “indirect key role” excluding several causes of hematic pericardial effusion (such as aortic dissection and solid tumors that could infiltrate the pericardial membrane), thirdly there are no other anamnestic events that may be associated with this clinical manifestation (such as trauma). The low flexibility of the Cardia Ultraseal (Cardia, Inc., Eagan, MN, USA) nitinol mesh structure, as previously reported in others settings, may be associated to increased torque of the device by the beating heart. A bench test showed that the Ultrasept, a large–mashed device for interatrial defect closure, very similar to Ultraseal, needs a high compression force during implantation as a result of its low radial strength. In addition, compared to other devices, the bulb part is much larger. Consequently, when the device is deeply inserted in LAA, a higher surface area within the appendage wall is directly overlapped, having more chance of causing friction.All these aspects could be responsible of wall erosion.

A prospective evaluation of the fourth national Be Clear on Cancer 'Blood in Pee' campaign in England.

ObjectiveTo assess the impact of the fourth Be Clear on Cancer (BCoC) ‘Blood in Pee’ (BiP) campaign (July to September 2018) on bladder and kidney cancer symptom awareness and outcomes in England.MethodsIn this uncontrolled before and after study, symptom awareness and reported barriers to GP attendance were assessed using panel and one‐to‐one interviews. The Health Improvement Network (THIN), National Cancer Registration and Analysis Service (NCRAS) and NHS Cancer Waiting Times (CWT) data were analysed to assess the impact on GP attendances, urgent cancer referrals, cancer diagnoses and 1‐year survival. Analyses used Poisson, negative binomial and Cox regression.ResultsSymptom awareness and intention to consult a GP after one episode of haematuria increased following the campaign. GP attendance with haematuria (rate ratio (RR) 1.17, 95% confidence interval (CI): 1.07–1.28) and urgent cancer referrals (RR 1.18 95% CI: 1.08–1.28) increased following the campaign. Early‐stage diagnoses increased for bladder cancer (difference in percentage 2.8%, 95% CI: −0.2%–5.8%), but not for kidney cancer (difference −0.6%, 95% CI: −3.2%–2.1%).ConclusionsThe fourth BCoC BiP campaign appears to have been effective in increasing bladder cancer symptom awareness and GP attendances, although long‐term impacts are unclear.